Healthcare Provider Details

I. General information

NPI: 1619243888
Provider Name (Legal Business Name): AMANDA BIGHORSE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2012
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395200 W 2900 RD
OCHELATA OK
74051-2463
US

IV. Provider business mailing address

395200 W 2900 RD
OCHELATA OK
74051-2463
US

V. Phone/Fax

Practice location:
  • Phone: 918-535-6000
  • Fax:
Mailing address:
  • Phone: 918-535-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5203
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: